Hand-Foot-and-Mouth Disease in Emergency Medicine Clinical Presentation

  • Author: Pamela L Dyne, MD; Chief Editor: Russell W Steele, MD  more...
 
Updated: Apr 10, 2016
 

History

The usual incubation period of hand-foot-and-mouth (HFM) disease is 4-6 days.

The prodrome is associated with the following:

  • Low-grade fever
  • Malaise
  • Anorexia
  • Abdominal pain
  • Sore mouth

The prodrome precedes the development of oral lesions, followed shortly by skin lesions, primarily on the hands and feet and occasionally on the buttocks.

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Physical

Hand-foot-and-mouth disease is the most common cause of mouth sores in pediatric patients.

Yellow ulcers surrounded by red halos characterize the oral lesions. These primarily occur on the labial and buccal mucosal surfaces but may be observed on the tongue, palate, uvula, anterior tonsillar pillars, or gums. Unlike herpetic gingivostomatitis, perioral lesions are uncommon. Coxsackie A virus also causes herpangina, mostly described as palatal and posterior oropharyngeal lesions without any associated exanthem. The oral ulcers are painful. Children younger than 5 years are predominately more symptomatic than older patients.[5]

The exanthem typically involves the dorsal surfaces but frequently may include the palmar, plantar, and interdigital surfaces of the hands and feet. These lesions may be asymptomatic or pruritic. They usually begin as erythematous macules that rapidly progress to thick-walled grey vesicles with an erythematous base. In young infants, these lesions may also be observed on the trunk, thighs, and buttocks. The rash is usually self-limited, lasting approximately 3-6 days. Case reports have documented subacute, chronic, and recurring skin lesions.

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Causes

See the list below:

  • The enteroviruses, specifically coxsackievirus A16, A-10, and A-5 predominate.
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Contributor Information and Disclosures
Author

Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Heather Kesler DeVore, MD Assistant Professor, Clinical Attending Physician, Department of Emergency Medicine, Georgetown University Hospital and Washington Hospital Center

Heather Kesler DeVore, MD is a member of the following medical societies: Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Stacy Sawtelle, MD Clinical Instructor, Department of Emergency Medicine, University of California, San Francisco, School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

William G Gossman, MD, FAAEM Associate Clinical Professor of Emergency Medicine, Creighton University School of Medicine; Chairman, Department of Emergency Medicine, Creighton University Medical Center

William G Gossman, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. Suzuki Y, Taya K, Nakashima K, et al. Study on Risk Factors for Severe Hand-foot-and-mouth Disease. Pediatr Int. 2009 Aug 3. [Medline].

  2. Wolff K, Johnson RA, Suurmond D. Viral infections of skin and mucosa. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. 5th ed. New York, NY: McGraw-Hill; 2005. 790-92.

  3. Xing W, Liao Q, Viboud C, Zhang J, Sun J, Wu JT, et al. Hand, foot, and mouth disease in China, 2008-12: an epidemiological study. Lancet Infect Dis. 2014 Apr. 14(4):308-18. [Medline]. [Full Text].

  4. Wang SM, Lei HY, Liu CC. Cytokine immunopathogenesis of enterovirus 71 brain stem encephalitis. Clin Dev Immunol. 2012. 2012:876241. [Medline]. [Full Text].

  5. Lott JP, Liu K, Landry ML, Nix WA, Oberste MS, Bolognia J, et al. Atypical hand-foot-and-mouth disease associated with coxsackievirus A6 infection. J Am Acad Dermatol. 2013 Nov. 69(5):736-41. [Medline].

  6. Nassef C, Ziemer C, Morrell DS. Hand-foot-and-mouth disease: a new look at a classic viral rash. Curr Opin Pediatr. 2015 Aug. 27 (4):486-91. [Medline].

  7. Hopper SM, McCarthy M, Tancharoen C, Lee KJ, Davidson A, Babl FE. Topical Lidocaine to Improve Oral Intake in Children With Painful Infectious Mouth Ulcers: A Blinded, Randomized, Placebo-Controlled Trial. Ann Emerg Med. 2013 Nov 7. [Medline].

  8. Chang LY, Tsao KC, Hsia SH, et al. Transmission and clinical features of enterovirus 71 infections in household contacts in Taiwan. JAMA. 2004 Jan 14. 291(2):222-7. [Medline].

  9. Chen KT, Chang HL, Wang ST, Cheng YT, Yang JY. Epidemiologic features of hand-foot-mouth disease and herpangina caused by enterovirus 71 in Taiwan, 1998-2005. Pediatrics. 2007 Aug. 120(2):e244-52. [Medline].

  10. Cherry JD. Enteroviruses: polioviruses, coxsackieviruses, echoviruses and enteroviruses. Textbook of Pediatric Infectious Diseases. 5th ed. 2005. 2007.

  11. Cherry JD. Viral exanthems. Curr Probl Pediatr. 1983 Apr. 13(6):1-44. [Medline].

  12. Davis H, Karasic R. Pediatric infectious disease. Atlas of Pediatric Physical Diagnosis. 3rd ed. 1997. 347-8.

  13. Marks M. Viral and presumably viral syndromes. Pediatric Infectious Diseases for the Practitioner. 1985. 494-6.

  14. Sasidharan CK, Sugathan P, Agarwal R, et al. Hand-foot-and-mouth disease in Calicut. Indian J Pediatr. 2005 Jan. 72(1):17-21. [Medline].

  15. Wang CY, Li Lu F, Wu MH, et al. Fatal coxsackievirus A16 infection. Pediatr Infect Dis J. 2004 Mar. 23(3):275-6. [Medline].

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The lower lip has an ulcer with an erythematous halo.
The tongue has an ulcer with an erythematous halo.
A typical cutaneous lesion has an elliptical vesicle surrounded by an erythematous halo. The long axis of the lesion is oriented along the skin lines.
 
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